A territory-wide retrospective study of >16,000 adult patients with moderate-to-severe asthma finds no difference in risk of pneumonia between budesonide and fluticasone propionate (FP) or fluticasone furoate (FF) users.
Inhaled corticosteroids (ICS) are the cornerstone of asthma treatment and are indicated at Global Initiative for Asthma (GINA) severity steps 3–5, regardless of exacerbation history. However, some ICS, such as fluticasone, have been shown to be associated with an increased risk of pneumonia in patients with chronic obstructive pulmonary disease (COPD).
“To date, data on pneumonia risks associated with different ICS in asthma are limited, primarily derived from a few observational studies,” wrote the researchers. “The aim of the current study is to compare the risks of pneumonia among patients with asthma prescribed budesonide or fluticasone, using a territory-wide electronic medical record database.” [Adv Ther 2026;doi:10.1007/s12325-026-03776-0]
The study included 16,170 adult patients (mean age, 63.1 years; male, 35.4 percent) with asthma (without COPD) of GINA severity step 3 (32.7 percent), 4 (15.5 percent) or 5 (51.8 percent) who were managed under the Hong Kong Hospital Authority in 2018 and were prescribed budesonide (44.3 percent), FP (48.6 percent) or FP (7.1 percent). The patients were followed up until December 2023.
A total of 1,675 patients (10.4 percent) developed pneumonia, with 732 (10.2 percent) and 943 (10.5 percent) in the budesonide and FF/FP groups, respectively. Among these patients, 626 (8.7 percent) in the budesonide group and 810 (9.0 percent) in the FF/FP group required hospitalization for pneumonia. There were 25 cases (0.3 percent) requiring ICU admission in the budesonide and 17 cases (0.2 percent) in the FF/FP group. Using budesonide as the reference group, crude and adjusted odds and hazard ratio analyses suggested that the risks of developing all pneumonia events, including those requiring hospitalization or ICU admission, were not significantly different among patients with asthma prescribed BUD or FF/FP.
“To ensure a more robust comparison of patient outcomes, we performed propensity score matching [PSM] including age, sex, GINA treatment steps, Charlson comorbidity index, ICS dosage, age at asthma diagnosis, and vaccination status on seasonal influenza vaccine, pneumococcal polysaccharide vaccine 23-valent, and 13-valent pneumococcal conjugate vaccine, which are potential confounding factors for pneumonia risk,” explained the researchers. “The results in the PSM cohort were consistent with the analyses in the primary cohort, without significant difference in pneumonia risks for budesonide or FF/FP.”
Subsequent subgroup analyses, which compared budesonide vs FP and budesonide vs FF, found no significant difference in pneumonia risks between the individual agents. The results in the PSM cohort were consistent with the analyses in the primary cohort.
“There was no significant difference in pneumonia risks for budesonide and FF/FP among patients with moderate-to-severe asthma who required ICS treatment,” concluded the researchers. “The choice between budesonide and FF/FP in asthma should be based on clinical control and other adverse effect profiles rather than concerns about pneumonia.”